Prenup Intake Questionnaire

YOUR PERSONAL INFORMATION:

Full Name: *

Today’s Date: *

Maiden Name, if applicable:

Any other name commonly used:

Place of Birth:

Address

City

State/Province

Zip/Postal

Country

County of Home Address:

Date lived at address since:

Which Address do you wish correspondence to be sent, or if you wish to have it sent to another address, provide that address:

Home Phone Number

Work Number

Cell Number

Fax Number

Email Address

Can we send billing/case information to that email

yes

no

Please indicate any restrictions/directions in calling you:

Please list any other home address (es) you’ve had for the past six (6) months:

Are you and your prospective spouse living together now?

INFORMATION ABOUT YOUR PROSPECTIVE SPOUSE:

Full Name:

Maiden Name, if applicable:

Any other name commonly used:

Address

City

State/Province

Zip/Postal

Country

County of Home Address:

Date lived at address since:

Home Phone Number

Work Number

Cell Number

Fax Number

Email Address

ADDITIONAL INFORMATION

On what date do you propose to be married?

How many living children does your prospective spouse presently have?

Name

Age

Financially Independent?

Any Disability?

Add Remove

How many children do you presently have?

Name

Age

Financially Independent?

Any Disability?

Add Remove

We strongly recommend that your prospective spouse have separate counsel in order to strengthen the effectiveness of the prenuptial agreement. If your prospective spouse will retain counsel, please furnish such counsel's name, address and telephone number.

Name:

Address

City

State/Province

Zip/Postal

Country

Number

ADDITIONAL INFORMATION

Will you and your prospective spouse exchange medical information?

Yes

No

Will you and your spouse exchange or permit disclosure of other information including but not limited to credit reports and information held by law enforcement agencies.

Yes

No

Where will the marital home be located?

City

State/Province

Zip/Postal

Country

Is this currently the home of one prospective spouse?

Yes

No

Name of Owner:

Does the other prospective spouse also own a home?

Yes

No

If so, adress:

City

State/Province

Zip/Postal

Country

Check below the form of ownership of the marital home.

owned by self

owned by spouse

owned jointly as tenants in common

owned jointly with right of survivorship

Check below the form of ownership of the marital home.

owned by self

owned by spouse

owned jointly as tenants in common

owned jointly with right of survivorship

Check below the form of ownership of the marital home.

owned by self

owned by spouse

owned jointly as tenants in common

owned jointly with right of survivorship

Check below the form of ownership of the marital home.

owned by self

owned by spouse

owned jointly as tenants in common

owned jointly with right of survivorship

Who will pay for the cost of the housing?

paid for equally by the parties

paid for by the parties in proportion to their net taxable income

paid for by self

paid for by spouse

With respect to automobile repair maintenance and replacement, will these expenses be:

paid for equally by the parties?

paid for by self

paid for by spouse

paid for by the parties in proportion to their net taxable income?

paid for by the party for whose benefit the cost was incurred?

With respect to routine living expenses, will they be:

paid for equally by the parties?

paid for by the parties in proportion to their net taxable income?

paid for by self?

paid for by spouse?

paid for by the party who made the purchase?

If new purchases of household furnishings will be made,

paid for equally by the parties?

paid for by the parties in proportion to their net taxable income?

paid for by self?

paid for by spouse?

paid for by the party who made the purchase?

Do you and your prospective spouse currently have health insurance?

yes

no

Please list coverage for you:

Please list coverage for your prospective spouse:

With respect to health insurance, will such premiums be:

paid for equally by the parties?

paid for by the parties in proportion to their net taxable income?

paid for by self?

paid for by spouse?

paid for by the party who made the purchase?

Unreimbursed medical expenses. These expenses are those rising out of deductibles or coinsurance. Such expenses will be:

paid for equally by the parties?

paid for by the parties in proportion to their net taxable income?

paid for by self?

paid for by spouse?

paid for by the party who made the purchase?

Catastrophic illness expense. A catastrophic illness expense is one that is not covered by health insurance or the limits of the insurance coverage have been exceeded. Such expenses will be:

paid for equally by the parties?

paid for by the parties in proportion to their net taxable income?

paid for by self?

paid for by spouse?

paid for by the party who made the purchase?

Do you currently have Long Term Care insurance?

Yes

No

If so, list coverage information.

Does your spouse currently have Long Term Care insurance?

Yes

No

If either does not have coverage, are there health issues that might prevent the purchase of Long Term Care Insurance?

Extraordinary expenses. These expenses are nonroutine, unusual expenses that are not medical expenses and not routine expenses. Such expenses will be:

paid for equally by the parties?

paid for by the parties in proportion to their net taxable income?

paid for by self?

paid for by spouse?

paid for by the party who made the purchase?

Tax returns. If from time to time you and your prospective spouse should find it beneficial to file a joint tax return, then the cost of the taxes and preparation will be:

paid for equally by the parties?

paid for by the parties in proportion to their net taxable income?

paid for by self?

paid for by spouse?

paid for by the party who made the purchase?

Tax returns. If from time to time you and your prospective spouse should find it beneficial to file a joint tax return, then the cost of the taxes and preparation will be:

paid for equally by the parties?

paid for by the parties in proportion to their net taxable income?

paid for by self?

paid for by spouse?

paid for by the party who made the purchase?

With respect to vacation and travel, such expenses will be:

paid for equally by the parties?

paid for by the parties in proportion to their net taxable income?

paid for by self?

paid for by spouse?

paid for by the party who made the purchase?

With respect to club memberships, the recurring cost of membership will be:

paid for equally by the parties?

paid for by the parties in proportion to their net taxable income?

paid for by self?

paid for by spouse?

paid for by the party who made the purchase?

If upon discussion with your prospective spouse you have agreed to do any of the following, please check the appropriate box and specify the details beneath:

Will you give prospective spouse the right to live in the marital residence for life, after your death?

Yes

No

Have you agreed to leave your prospective spouse any specific property in your will?

Yes

No

If so, describe

Have you agreed to leave your prospective spouse any cash money?

Yes

No

If so, how much?

Have you agreed to name your prospective spouse as beneficiary of any life insurance proceeds?

Yes

No

If so, please state policy number, name of company and face amount of proceeds?

Have you agreed to name your spouse as beneficiary of any employment benefits?

Yes

No

If so, name of employee benefit plan?

Have you agreed to own any assets jointly with your prospective spouse with right of survivorship?

Yes

No

If so, describe such property.

ASSET INFORMATION:

1. Real Property: At some point we will need to review copies of all deeds in order to verify the manner in which title to the property is held. Details regarding each parcel of real property may be written on a separate sheet of paper and attached to this form. In each case, please indicate the current value of the asset and any mortgage amounts, including home equity loans. Lastly, state if the property is held jointly or otherwise and if jointly, with whom.

Residence/ Self:

Residence/ Spouse:

Recreational Property/ Self:

Recreational Property/ Spouse:

Investment Property/ Self:

Investment Property/ Spouse:

Total current value of real property/ Self:

Total current value of real property/ Spouse:

3. Closely held stock. Give details regarding any interests you have in a corporation that is closely held (i.e., the stock is not publicly traded).

4. Accounts in Financial Institutions:

Checking / Self

Bank name & location / Approximate balance

Checking / Spouse

Bank name & location / Approximate balance

Saving / Self

Bank name & location / Approximate balance

Saving / Spouse

Bank name & location / Approximate balance

Certificates of deposit / Self

Bank name & location / Approximate balance

Certificates of deposit /Spouse

Bank name & location / Approximate balance

Mutual Funds, Money Market accounts, IRAs or other investment accounts / Self

Bank name & location / Approximate balance

Mutual Funds, Money Market accounts, IRAs or other investment accounts/ Spouse

Bank name & location / Approximate balance

5. Life insurance

Company/ Self

Company/ Spouse

Face amount/ Self

Face amount / Spouse

Loans outstanding on policy (if any)/ Self

Loans outstanding on policy (if any)/ Spouse

Type (term, ordinary life, or other)/ Self

Type (term, ordinary life, or other) / Spouse

Owner of Policy/ Self

Owner of Policy/ Spouse

Beneficiaries designated in policy/ Self

Beneficiaries designated in policy/ Spouse

Pets/ Self / Spouse

Pets / Spouse

Jewelry/ Self

Jewelry/ Spouse

Antiques/ Self

Antiques/ Spouse

Art Objects/ Self

Art Objects/ Spouse

Automobiles/ Self

Automobiles/ Spouse

Boats/ Self

Boats/ Spouse

Airplanes/ Self

Airplanes/ Spouse

Stamps, coins, or other collections/ Self

Stamps, coins, or other collections / Spouse

Other personal property/ Self

Other personal property/ Spouse

7. Describe any employee benefit plans in which client has an interest. Indicate whether or not the plans are qualified plans under the federal income tax law, the approximate value of interests in the plans, and how payments will be made in the event of the death or retirement of the participant.

8. Describe any interests that client has in any other deferred compensation contracts or plans.

9. Describe any other assets in which client may have an interest.

10. Describe any debts of client that are not reflected in any of the lists of assets.

11. What is the approximate present net worth of client, excluding life insurance?

12. Location of any safe deposit boxes maintained by client.

13. List the resale value of club memberships of client.